dextromethorphan hbr-quinidine sulfate — Blue Cross Blue Shield of Illinois

Initial criteria

• The patient has a diagnosis of pseudobulbar affect (PBA)
• The patient has ONE of the following: amyotrophic lateral sclerosis (ALS) OR multiple sclerosis (MS) OR dementia OR stroke OR traumatic brain injury
• The prescriber has assessed the patient's PBA episodes (laughing and/or crying episodes) prior to therapy with the requested agent
• The prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist, neuropsychologist, psychiatrist) OR has consulted with such a specialist
• The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• The patient has been previously approved for the requested agent through the plan’s Prior Authorization process
• The patient has had clinical benefit with the requested agent
• The prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist, neuropsychologist, psychiatrist) OR has consulted with such a specialist
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months (BCBSIL); 3 months (others initial); 12 months (others renewal)